asepsis is deined as

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. Asepsis is defined as ________________.

A. the absence of all microorganisms
B. the absence of disease-causing germs
C. a urinary infection
D. a pathogenic infection

Correct answer: B

Rationale: Asepsis is defined as the absence of disease-causing germs. It is surgical asepsis that is defined as the absence of all microorganisms, including spores. A pathogenic infection is an invasion of the body by a pathogen, or disease-causing germ, and a urinary infection is only one type of infection.

2. Mr. W has orders for a physical therapy consult. The nurse contacts the appropriate department but 12 hours later, no one has come to see the client. Which is the most appropriate action of the nurse?

A. Call the supervisor and file a complaint against the physical therapy department
B. Contact the physician to notify him that the orders were not carried out
C. Assess the client's activity level by assisting with ambulation using a gait belt
D. Contact the physical therapy department again and repeat the order

Correct answer: D

Rationale: In this situation, the most appropriate action for the nurse to take is to contact the physical therapy department again and repeat the order. It is crucial to ensure that the client receives the necessary care as prescribed. Following up with the department reinforces the importance of the order and increases the likelihood of prompt action. Option A is incorrect because escalating the situation to filing a complaint should be a last resort after all other communication attempts have failed. Option B is not the best course of action as the first step should be to ensure proper communication within the healthcare team. Option C is not the priority in this scenario, as the immediate concern is to address the delay in the physical therapy consult.

3. A client is preparing to give a stool sample for occult blood. All of the following information is part of teaching for this client EXCEPT:

A. Avoid eating red meat for 3 days before the test
B. Collect the stool sample from the toilet after having a bowel movement
C. The stool does not need to be kept in a container with preservative
D. A small part of the stool from two areas will be tested using a smear

Correct answer: B

Rationale: When preparing to give a stool sample for occult blood testing, clients need specific instructions to ensure accurate results. It is crucial to educate clients to avoid eating red meat for at least 3 days before the test, as the blood in the meat can interfere with the test results. Clients should be informed that the stool does not need to be kept in a container with preservative as it is not required for this type of testing. Additionally, clients should be aware that a small part of the stool from two areas will be tested using a smear. However, collecting the stool sample from the toilet after having a bowel movement is not recommended as it may introduce contaminants and affect the accuracy of the test. Therefore, this information is not part of the correct teaching for the client preparing to give a stool sample for occult blood.

4. A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select one that doesn't apply.

A. Regular developmental screening is important to avoid secondary developmental delays.
B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.
C. Developmental milestones may be slightly delayed but usually will require no additional intervention.
D. Parent support groups are helpful for sharing strategies and managing health care issues.

Correct answer: C

Rationale: The correct answer is 'Developmental milestones may be slightly delayed but usually will require no additional intervention.' This statement is incorrect as delayed developmental milestones in a child with cerebral palsy require interventions and constant follow-ups. Developmental monitoring is essential to track a child's growth and development over time. If any concerns are raised during monitoring, a developmental screening test should be conducted promptly to address any developmental delays or issues. Regular interventions, therapies, and support are crucial to optimize the child's development and well-being. Therefore, it is important for parents to be aware that additional interventions may be necessary to support their child's development.

5. Which of the following is a local sign of infection?

A. Swelling
B. Rapid pulse
C. Fever
D. High white blood count

Correct answer: A

Rationale: A local sign of infection refers to symptoms that are specific to the area of infection. Swelling, heat, pain, and redness near the infected site are examples of local signs. In the context of infection, swelling occurs due to an accumulation of fluid and immune cells at the site of infection. Rapid pulse, fever, and high white blood count are more systemic responses to infection and not specific local signs. Rapid pulse can indicate systemic distress or sepsis, fever is a systemic response to infection, and high white blood count is a laboratory finding that suggests an immune response but is not a direct sign of infection at a specific site.